Concerns raised 4 Failure to immediately admit children when meningitis is a realistic possibility View source Failure to immediately refer children with infected umbilical cords to hospital at first OOH attendance View source Lack of facility for simple blood testing in the GP out-of-hours setting View source Failure to escalate seriously ill children to hospital during OOH assessment View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mikey James Hornby · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mikey James Hornby was born on 31 March 2014 and died after being found lifeless at home on the morning after he attended an out-of-hours service with strange breathing. The report records neonatal E. coli sepsis and meningitis, with the conclusion of natural causes contributed to by neglect. Concerns included failures to refer him to hospital when he had an infected umbilical cord or possible serious illness, and the lack of access to immediate blood testing and antibiotics.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cheshire and Mersey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to immediately admit children when meningitis is a realistic possibility
Wider context from the report “1. On the first attendance at the OOH service, the attending staff having seen the infected umbilical cord, did not immediately send Mikey to the Hospital (as would have been the correct procedure according to the Consultant Lead Paediatrician who gave evidence to me.)
2. On the second attendance the doctor failed to appreciate the seriousness of the situation and at 10.45 at night sent the child home with a prescription for analgesia (which could not be filled until the following day in any event). The Consultant Paediatrician gave evidence to me “that there was a very high probability that he would have survived” had he been sent to the hospital at this time as he could and would have been administered an intra-venous anti-biotic.
3. If there is any realistic possibility of the condition being meningitis, the child should have been immediately admitted to the hospital .
4. The GP covering the surgery that night indicated that they do not have the facility to take a simple blood test. If this is the case, then they should utilise the adjacent facilities at the Emergency Department of the hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cheshire and Mersey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to immediately refer children with infected umbilical cords to hospital at first OOH attendance
Wider context from the report “1. On the first attendance at the OOH service, the attending staff having seen the infected umbilical cord, did not immediately send Mikey to the Hospital (as would have been the correct procedure according to the Consultant Lead Paediatrician who gave evidence to me.)
2. On the second attendance the doctor failed to appreciate the seriousness of the situation and at 10.45 at night sent the child home with a prescription for analgesia (which could not be filled until the following day in any event). The Consultant Paediatrician gave evidence to me “that there was a very high probability that he would have survived” had he been sent to the hospital at this time as he could and would have been administered an intra-venous anti-biotic.
3. If there is any realistic possibility of the condition being meningitis, the child should have been immediately admitted to the hospital.
4. The GP covering the surgery that night indicated that they do not have the facility to take a simple blood test. If this is the case, then they should utilise the adjacent facilities at the Emergency Department of the hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cheshire and Mersey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of facility for simple blood testing in the GP out-of-hours setting
Wider context from the report “1. On the first attendance at the OOH service, the attending staff having seen the infected umbilical cord, did not immediately send Mikey to the Hospital (as would have been the correct procedure according to the Consultant Lead Paediatrician who gave evidence to me.)
2. On the second attendance the doctor failed to appreciate the seriousness of the situation and at 10.45 at night sent the child home with a prescription for analgesia (which could not be filled until the following day in any event). The Consultant Paediatrician gave evidence to me “that there was a very high probability that he would have survived” had he been sent to the hospital at this time as he could and would have been administered an intra-venous anti-biotic.
3. If there is any realistic possibility of the condition being meningitis, the child should have been immediately admitted to the hospital.
4. The GP covering the surgery that night indicated that they do not have the facility to take a simple blood test . If this is the case, then they should utilise the adjacent facilities at the Emergency Department of the hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Cheshire and Mersey NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate seriously ill children to hospital during OOH assessment
Wider context from the report “1. On the first attendance at the OOH service, the attending staff having seen the infected umbilical cord, did not immediately send Mikey to the Hospital (as would have been the correct procedure according to the Consultant Lead Paediatrician who gave evidence to me.)
2. On the second attendance the doctor failed to appreciate the seriousness of the situation and at 10.45 at night sent the child home with a prescription for analgesia (which could not be filled until the following day in any event). The Consultant Paediatrician gave evidence to me “that there was a very high probability that he would have survived” had he been sent to the hospital at this time as he could and would have been administered an intra-venous anti-biotic.
3. If there is any realistic possibility of the condition being meningitis, the child should have been immediately admitted to the hospital.
4. The GP covering the surgery that night indicated that they do not have the facility to take a simple blood test. If this is the case, then they should utilise the adjacent facilities at the Emergency Department of the hospital.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide training on managing severely ill children for out-of-hours GPs alongside mandatory and statutory training.
Verbatim wording from the response “Annual appraisals take place with all staff. Learning from incidents in service allows GPs to review their training needs so that alongside maintaining their annual Mandatory and Statutory Training, particular development needs can be met. For GPs in the Out of Hours Service, their Bridgewater-specific training will often run alongside the continuing professional development they undertake as part of their practice. In ████████ case, he has undertaken training on management of the severely ill child to support his general practice role.” Source location 2014-0536-Response-by-Bridgewater-Community-Healthcare-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct quarterly clinical audits of practitioners’ records and provide supervision and competency action plans where practice falls short.
Verbatim wording from the response “Ongoing checks on the quality of the services we provide are made via quarterly clinical audit reviews, where a sample of clinical and medical records from each practitioner are reviewed by the clinical director enabling best practice to be recognised and shared with colleagues. Where best practice is not followed a period of supervision and formal support with competency improvement action plans is implemented.” Source location 2014-0536-Response-by-Bridgewater-Community-Healthcare-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement NICE feverish-illness guidance in the out-of-hours service using PEWS and assessment templates.
Verbatim wording from the response “In 2013, the Trust implemented national NICE guidance dated May 2013 entitled “Feverish illness in children: Assessment and initial management in children younger than 5 years” which is based on validated algorithms. A copy of a link to the NICE guidance is enclosed, for your ease of reference: http://www.nice.org.uk/cg160/chapter/recommendations.” Source location 2014-0536-Response-by-Bridgewater-Community-Healthcare-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The service does not routinely perform paediatric blood tests; referral directly to hospital paediatricians is considered sufficient, rather than using the Emergency Department.
Verbatim wording from the response “In common with any GP practice, the GP Out of Hours service does not routinely take blood from children, including urgent circumstances, as we would not receive a report back in a timely enough manner to influence our decision making. If a practitioner felt that a blood test was likely to be important to the clinical decision making process, there is a clear referral protocol to the Paediatric department. A&E is not a referral route that we would use as there are pathways for an emergency referral to be made directly to the Paediatricians rather than patients waiting unnecessarily in A&E. At the time ████████, that a blood test was not deemed necessary, as evidenced through the NICE guidelines but if it had have been, an emergency referral to the Paediatricians would have been made.” Source location 2014-0536-Response-by-Bridgewater-Community-Healthcare-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The clinical data produced a PEWS score of 0–2, which did not indicate that further action or hospital referral was required.
Verbatim wording from the response “The Trust is fully compliant with this guideline. The Trust uses the Paediatric Early Warning Score (PEWS) system in the GP Out of Hours service as a way of ensuring that the steps recommended in the NICE guidance are considered (please see attachment one). Although the score sheet was not available during ████████ examination of Baby Mikey, running the score from the clinical data of the consultation showed the score is 0-2 which did not indicate further action was required.” Source location 2014-0536-Response-by-Bridgewater-Community-Healthcare-NHS-Trust
Open published response
Pin
Request correction
Addressed to Bridgewater Community Healthcare NHS Foundation Trust, now represented here by North Cheshire and Mersey NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations